Neurosciences for PLAB 1

A 68 year old man developed sudden right-sided weakness and slurred speech 90 minutes ago. His right arm is flaccid with power 1/5 and there is a right facial droop sparing the forehead. His blood pressure is 176/94 mmHg and capillary glucose 6.4 mmol/L. Non-contrast CT head shows no haemorrhage. What is the SINGLE most likely diagnosis?

1. Migraine with aura Flashing lights or other visual changes that spread out over minutes, followed by a headache, in a younger patient who has had this before. Here, started 90 minutes ago, with bleeding ruled out points elsewhere.
2. Stroke correct Correct. A sudden loss of brain function with the forehead still working normally, which places the facial weakness in the brain rather than the nerve itself, and separates it from Bell palsy. His blood sugar has already ruled out the mimic that matters most.
3. Hypoglycaemia Low blood sugar. It can look exactly like a stroke, and it can be fixed straight away, which is why a blood sugar (glucose) test is done in every suspected stroke. But started 90 minutes ago, with bleeding ruled out does not point to it.
4. Space-occupying lesion A growth taking up space in the brain. It causes a problem that gets worse over weeks, with a headache that is worse in the morning and swelling at the back of the eye (papilloedema). That does not match started 90 minutes ago, with bleeding ruled out.
5. Todd paresis Short-lived weakness after a seizure (fit), which goes away over hours. It does not fit started 90 minutes ago, with bleeding ruled out.

The point: Give everyone a CT scan of the head straight away (non-contrast CT head). The only question that matters at first is whether this is bleeding (a haemorrhage) or a blocked artery. If bleeding is ruled out, give clot-busting medicine (thrombolysis) within 4.5 hours. A clot-removal procedure (thrombectomy) can be done up to 24 hours later in chosen cases of a blocked large artery. If clot-busting medicine is not given, give aspirin 300 mg for 14 days. Do NOT lower the blood pressure quickly in a stroke caused by a blocked artery (ischaemic stroke), unless clot-busting medicine is being given.

Source: NICE NG128 — Stroke and transient ischaemic attack in over 16s NICE · tier 1, national regulator or guidance

A 68 year old man developed sudden right-sided weakness and slurred speech 90 minutes ago. His right arm is flaccid with power 1/5 and there is a right facial droop sparing the forehead. His blood pressure is 176/94 mmHg and capillary glucose 6.4 mmol/L. Non-contrast CT head shows no haemorrhage. What is the SINGLE most appropriate immediate management?

1. Mechanical thrombectomy A procedure to physically remove the clot. Used for a confirmed blocked large artery, up to 24 hours later in chosen patients whose brain tissue can still be saved. It does not fit started 90 minutes ago, with bleeding ruled out.
2. Urgent neurosurgical referral Sending the patient to a brain surgery team straight away, needed for bleeding that is pushing on the brain, fluid building up in the brain, or a blood clot at the back of the brain. Here, started 90 minutes ago, with bleeding ruled out points elsewhere.
3. Intravenous thrombolysis with alteplase correct Correct. Given within 4.5 hours of a clearly seen start, with bleeding ruled out and no reason not to give it. His blood pressure of 176/94 is below the 185/110 cut-off and does NOT need lowering. Lowering it in an untreated blocked-artery stroke reduces blood flow to the brain tissue that could still be saved.
4. Reverse anticoagulation Undoing the effect of a blood thinner. Used for bleeding in the brain in a patient on warfarin or a direct oral anticoagulant, with a clotting-factor drug plus vitamin K, or the specific drug that reverses that blood thinner. But started 90 minutes ago, with bleeding ruled out does not point to it.
5. Start anticoagulation immediately Starting a blood thinner straight away. This is put off for up to two weeks after a large stroke, because of the risk of the stroke turning into a bleed, even if the patient has an irregular heart rhythm. That does not match started 90 minutes ago, with bleeding ruled out.

The point: Give everyone a CT scan of the head straight away (non-contrast CT head). The only question that matters at first is whether this is bleeding (a haemorrhage) or a blocked artery. If bleeding is ruled out, give clot-busting medicine (thrombolysis) within 4.5 hours. A clot-removal procedure (thrombectomy) can be done up to 24 hours later in chosen cases of a blocked large artery. If clot-busting medicine is not given, give aspirin 300 mg for 14 days. Do NOT lower the blood pressure quickly in a stroke caused by a blocked artery (ischaemic stroke), unless clot-busting medicine is being given.

Source: NICE NG128 — Stroke and transient ischaemic attack in over 16s NICE · tier 1, national regulator or guidance

A 68 year old man developed sudden right-sided weakness and slurred speech 90 minutes ago. His right arm is flaccid with power 1/5 and there is a right facial droop sparing the forehead. His blood pressure is 176/94 mmHg and capillary glucose 6.4 mmol/L. Non-contrast CT head shows no haemorrhage. What is the SINGLE most appropriate definitive management?

1. Mechanical thrombectomy A procedure to physically remove the clot. Used for a confirmed blocked large artery, up to 24 hours later in chosen patients whose brain tissue can still be saved. That does not match started 90 minutes ago, with bleeding ruled out.
2. Aspirin 300 mg for 14 days correct Correct. Started 24 hours after the clot-busting medicine, once a repeat scan has ruled out bleeding into the stroke area, then continued for two weeks before switching to long-term prevention treatment.
3. Reverse anticoagulation Undoing the effect of a blood thinner. Used for bleeding in the brain in a patient on warfarin or a direct oral anticoagulant, with a clotting-factor drug plus vitamin K, or the specific drug that reverses that blood thinner. Here, started 90 minutes ago, with bleeding ruled out points elsewhere.
4. Start anticoagulation immediately Starting a blood thinner straight away. This is put off for up to two weeks after a large stroke, because of the risk of the stroke turning into a bleed, even if the patient has an irregular heart rhythm. But started 90 minutes ago, with bleeding ruled out does not point to it.
5. Lower the blood pressure with intravenous labetalol A blood pressure drug given through a vein. Only used when giving clot-busting medicine, or in bleeding. Lowering the blood pressure in an untreated blocked-artery stroke reduces blood flow to the brain tissue that is still struggling but alive. It does not fit started 90 minutes ago, with bleeding ruled out.

The point: Give everyone a CT scan of the head straight away (non-contrast CT head). The only question that matters at first is whether this is bleeding (a haemorrhage) or a blocked artery. If bleeding is ruled out, give clot-busting medicine (thrombolysis) within 4.5 hours. A clot-removal procedure (thrombectomy) can be done up to 24 hours later in chosen cases of a blocked large artery. If clot-busting medicine is not given, give aspirin 300 mg for 14 days. Do NOT lower the blood pressure quickly in a stroke caused by a blocked artery (ischaemic stroke), unless clot-busting medicine is being given.

Source: NICE NG128 — Stroke and transient ischaemic attack in over 16s NICE · tier 1, national regulator or guidance